1.0 contact hour (60 min)
$39.99
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Orthopedics · 6 min read · September 27, 2026
From the course: Blood Flow Restriction Training After Orthopedic Surgery: A Scoping Review and a Randomized Trial · 1.0 contact hour
Listen while you read — the episodes from this course
Blood Flow Restriction After Surgery: What the Review Found Part 1 of 3 · 9 min
Blood Flow Restriction vs Heavy Load After ACL Reconstruction Part 2 of 3 · 8 min
Blood Flow Restriction After Surgery: What the Evidence Shows Part 3 of 3 · 8 min
Can low-load blood flow restriction training take the place of heavy-load strengthening in the first weeks after orthopedic surgery? Two papers published in JOSPT Open in 2026 give a partial answer. Koc and colleagues randomized 28 patients after bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstruction and found that low-load training with a thigh cuff and conventional heavy-load training produced comparable quadriceps and hamstring strength at 14 weeks. In a scoping review of 30 studies, Wang and colleagues found that the protocol used in that trial is the one most often published after orthopedic surgery, although most of those studies are small and involve the knee. Koc and colleagues described the low-load approach as a possible alternative for patients who cannot tolerate heavy loading, and they cautioned that their small sample does not establish that the two are equivalent.
Wang and colleagues cite a recommendation from the American College of Sports Medicine of about 70% of a one-repetition maximum for strengthening, and they describe blood flow restriction as producing muscular development at 20% to 40% of that maximum. In both papers, cuff pressure is mostly expressed as a percentage of occlusion pressure, which Koc and colleagues define as the least pressure needed to occlude blood flow.
Wang and colleagues searched four databases through July 2024 for studies that started blood flow restriction training within six months of an orthopedic procedure and reported a functional or patient-reported outcome. From 4,048 records, two independent reviewers included 30 studies covering 831 patients, 17 of them randomized trials. Twenty-one of the 30 appeared in 2022 or later.
The knee dominated. ACL reconstruction accounted for 18 studies (60%) and nonreconstructive knee arthroscopy for 5, with the remainder spread across fracture fixation, high tibial osteotomy, knee arthroplasty, shoulder stabilization and distal biceps repair. Eighteen studies followed patients for less than three months, and only two followed them beyond six months.
Wang and colleagues found a recognizable core protocol:
Outside that core, pressures ranged from 40% of occlusion pressure to fixed settings of 180 mmHg. Two trials, one after high tibial osteotomy and one after ACL reconstruction, compared 40% with 80% of arterial occlusion pressure. In both, the reviewers report that 80% was the more effective setting for preventing muscle atrophy and improving strength, with the benefit measured against a control group that received no blood flow restriction.
Koc and colleagues conducted their trial with 28 young, recreationally active patients having a first ACL reconstruction with a bone-patellar tendon-bone autograft at Zuyderland Medical Center in the Netherlands, randomized to two groups of 14. Strength training began two weeks after surgery, but only once a patient reached knee motion of 0° to 90°, showed no more than minimal effusion on the stroke test and could perform repeated straight leg raises without an extension lag. Both groups then exercised twice a week until 14 weeks with leg press, seated leg extension, deadlift and squat.
| Parameter | Low-load blood flow restriction | Heavy-load resistance training |
|---|---|---|
| Load | 30% of the one-repetition maximum | 70% of the one-repetition maximum |
| Sets and repetitions | Four sets: 30, 15, 15, 15 | Three sets: 10, 10, 10 |
| Cuff | 80% of limb occlusion pressure during each exercise, deflated between exercises | None |
| Progression | Load raised 10% after two consecutive complete sessions | Load raised 10% after two consecutive complete sessions |
At 14 weeks, isokinetic quadriceps and hamstring strength showed no clear difference between the groups at any of the three test speeds. The secondary outcomes all leaned toward the cuff group: increased knee pain in the 24 hours after training was reported by 2 patients in the cuff group and 5 in the heavy-load group, effusion was present in 1 and 5, a flexion deficit in 1 and 4, and an extension deficit in none and 2. The authors reported that none of these comparisons held up as a real difference. Attendance was 92% of scheduled sessions with the cuff and 95% with heavy load, which the authors attributed to the criteria-based start.
Two earlier trials in patients with hamstring grafts had reported better strength and greater pain reduction with low-load cuff training than with heavy loading. Koc and colleagues attribute part of the contrast to graft type and part to differences in training tolerance and exercise volume.
Koc and colleagues excluded anyone with a history of venous thromboembolism, sickle cell anemia, hypertension or diabetes mellitus. One patient was withdrawn after becoming dizzy during the first cuff session. The authors cite a reported incidence of fainting during low-load cuff training below 4% and note that cuff tightness, pain, stress or anxiety may contribute. They recommend an individualized pressure between 40% and 80% of limb occlusion pressure, starting at the lower end so patients can become familiar with the cuff.
The two papers differ on that lower bound. Wang and colleagues say future studies should consider 50% to 80% of arterial occlusion pressure, while Koc and colleagues cite a systematic review reporting similar strength gains at 40% and 80%.
In the United States, screening and the choice of occlusion pressure rest with the physical therapist, and a physical therapist assistant may carry out established sessions under the physical therapist's direction and supervision.
Koc and colleagues identified sample size as their most consequential weakness: the trial did not reach its intended enrollment once withdrawals were counted, so a genuine difference could have been missed. Patients and staff could not be blinded, which leaves room for a novelty effect from the cuff. Pain, effusion and motion were recorded only as yes or no, total training volume was never tallied, and follow-up ended at 14 weeks.
Wang and colleagues noted that the concentration on knee procedures limits how far the findings transfer to other body regions, and that protocols and outcome measures varied too widely for studies to be combined. None of the included randomized trials were blinded, and the review protocol was not registered in advance. The reviewers call for more randomized work in fracture care and the upper limb.
In Wang and colleagues' review, 80% of arterial occlusion pressure was the setting reported most often, and Koc and colleagues used 80% of limb occlusion pressure in their ACL trial. The teams differ on how low the pressure can go: Wang and colleagues say future studies should consider 50% to 80%, and Koc and colleagues recommend an individualized 40% to 80%, starting low.
In Koc and colleagues' trial of 28 patients with bone-patellar tendon-bone grafts, the two approaches produced comparable strength, pain, effusion and range of motion at 14 weeks. The authors framed low-load cuff training as an option for patients who cannot tolerate heavy loading or have contraindications to it, and they did not propose it as a general replacement.
Just over half of the studies in Wang and colleagues' review began within two weeks of surgery, and the reviewers write that starting around two weeks appears to be well accepted, although further study is needed to confirm it. In the Koc trial, training began at two weeks once each patient met the entry criteria.
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